Tuesday, 27 May 2008

Community Pharmacists

I work with good GPs. I have a good relationship with them. Since joining this Trust, no GP has ever referred a problem as urgent and not had it attended to within 24 hours. No urgent emergency has has to wait more than 4 hours. We're audited on this every month, so I know we're a responsive service, which GPs appreciate.

Because of this relationship we've developed, there's been a healthy dose of common sense between Primary and Secondary Care.

Say a drug dose changes and a patient needs an ECG doing in a couple weeks but it's a way to trawl to the hospital, most GPs have no issue with the ECG being done in their surgery by their Practice Nurse. It's eating up a bit of their Practice Nurse time, it's generating no income for them, they have to mail the ECG to me, the ECG can be done in the hospital, but to smooth out things for their patients they offer this choice.

I take on and manage and follow up patients who are outwith our operational policy, but if I didn't do this they'd cause chaos and difficulties for the GP.

To date it's worked well, we blur boundaries, support one another and take policies/protocols with a pinch (well, more huge great handfuls) of salt and simply crack on and do what's best.

I like this.

Recently, one group of practices has appointed a new pharmacist. She's keen. She's determined to bring prescribing costs down. She's never met me. She has written to me, prolifically. A few things concern her. Well, that's disingenuous, I assume they don't concern her since she's a pharmacist with the salient information to hand so will know that the prescribing is rational and appropriate. What concerns her is the cost. Through this, she's notionally concerned that :

Lorazepam

Some patients with dementia are on lorazepam. They were battering people and were unmanageable. Now they're on 2mg of lorazepam regularly with some prn and are cured. They're in care homes with regular nurse follow up to ensure that the care homes use the minimum dose and complete diraies/use behavioural programmes rather than focus on medication. But although none of them are on more than 4mg of lorazepam, the British National Formulary (BNF) states a dose of lorazepam of 4mg in adults, 2mg in the elderly. These folks can sometimes have more than 2mg.

Of course, it's titrated to clinical need, there are no treatment emergent adverse events and it's working. So we use medication at the minimum effective dose, but that minimum is sometimes above 2mg. It's better than using lots of drugs at low (less effective/ineffective) dose. Our Royal College and voluntary groups advocate this.

She's asking that I undertake prescribing for all these patients, removing all such prescribing from the GPs. More than asking, she's saying that she's not willing for the GPs to prescribe these.

I'm sorely tempted to write back and suggest if she wants to change their drug regimen, go ahead and good luck.

Antipsychotic medication

A number of patients are on antipsychotic medication because of their dementia, causing memory loss and changes in thought so they're less adept at reality testing and become muddled. Antipsychotics can help smooth out chaotic thoughts so they can grasp the right train of thought more successfully more of the time. Also it can help with distress, helping folk feel less distraught. In some dementias people have delusions. They lose things, through poor memory, then try and understand why and reason it's been stolen, then look around over time and are mildly disoriented which fits with intruders, then develop abberant ideation as cognition deteriorates so can become deluded, with paranoid delusions. Antipsychotics can help these. Some will hallucinate. Antipsychotics can help these, too.

The BNF does not list licenced indications of Behavioural and Psychological Symptoms of Dementia for any drugs. Dementia care, with medication, is almost all outside the listed Summary of Product Characteristics (SPC) that all drugs have. The trials needed to get this evidence base, to change their SPC, aren't easy. They're not cost effctive and they're ethically fraught. Almost all prescribing in old age psychiatry is "off label" and outwith what the SPC says. A pharmacist will know this because the BNF has few modern drugs that we use that are developed with trials in older adults.

No means no!

I have no desire to take on routine prescribing responsibility for every patient with dementia. I have no computer for repeat prescriptions, all my prescribing is thoughtful and individual. If it is routine my GPs kindly undertake it.

What to do, what to do :- thank her for her point of view and ignore the issue?- decline to accept all these patient and let her GPs face her harrassment?- decline to accept and advise her to discuss changes with her GPs?- decline to accept and suggest that the drug plans are sound and that she change them at her peril?

It's folk like this that afford me an unhealthy glimpse in to how folk like Dr Rant can become so, erm, effusively colourful, in their frustrations with what's in essence unhelpful meddling.

13 comments:

I am stunned, although I dont quite know why. Use your last idea...its the most sound..and might also give her a rap on her knuckles. I have no doubt she is keen, and wants to do a really good job....but what she has suggested to you is arrogant to say the least.

In Canada..Manitoba at least, they are looking to permit pharmacists to write prescriptions. This scares me more than a little bit. I prefer to be given a medication only after a doctor I trust, has evaluted and diagnosed me. Sheesh!

Please Shrink, do not confirm my suspicion, who pays for the prescription if you prescribe, the Trust you work for or is it still from the PCT budget. I have been retired too long but I used to work for the Old NHS. “Is it cost or is it clinical?”

As such, if I'm generating scores of scripts each month, it costs our Trust.

The crunch is that if, as she's suggesting, I prescribe instead of GPs then I'll be prescribing for all these patients with dementia, forever, and I'll be getting scores of new referrals each month to prescribe for too.

Every month, I'll have more work to do, more cost to our Directorate, no benefit to patient care.

"Every month, I'll have more work to do, more cost to our Directorate, no benefit to patient care."

Yes but just think how much money it will save the PCT. Joined up thinking and collaborative working as such buzz words for new Labour, but their policies are old Tory. Just like fundholding and all the other divisive free market ideas that came along under Thatcher, PBC, purchasers and providers PFI and all those other p's which mean privatisation are bad for professionals working together in a true atmosphere of mutual respect and no good for patients either.

Thanks for confirming that I am not paranoic. Let us return to old fashion medical consultation with the GP in attendance and then the consultant suggest whatever treatment that the GP will then follow. That was before the NHS.

Final option with the letter copied to the GPs. Explain the rationale behind the current plans and how they are in the patients best interests and you strongly advise against changing the way things work currently (both who prescribes for these patients and what they are prescribed). If the GPs appreciate what a good working relationship you have then I am sure they will soon quash these ideas and advise her that she is doing a fantastic job but that this is one particular area they feel she does not need to interfere with. If it ain't broke, don't fix it.

Until we can somehow remove the DOC eat DOC situation, there will be some more cost conscious practice that will be doing that. I suspect too that there is some form of performance related bonus in all of this.

Why change what works well? Unfortunately your post exemplifies perfectly the trend that the NHS is following. Last option for sure, but and I agree with Kelly that you should let the GPs know what is going on. Especially since you have such a good relationship with them, they need to know your rationale.

Ask her how she got on when she told all the Endocrinologists they would be prescribing insulin; or Cardiovascular medics to prescribe anti-hypotensives.

Surely also you prescribing would require you to review them all also.

She's employed by the GP practices and no doubt, should their collegial professionalism and common sense prevail, they will empathise with your POV and tell her to stop her pedantic nonsense.

Of course, if they are in collusion then you should write to the GP practice(s) and outline your charge for every patient they require you to review. This, of course, may offset their prescribing cost savings "a little".

Well if there's a Service Level Agreement or Contract - just tell them you'll review the idea, calculate the increase in costs to your service and then pass that on to them in the annual business plan next financial year.That's the whole idea of the internal market - to make people more accountable for how they spend their money AND the service time.

Why Lake Cocytus?

Dante's "Inferno" takes us on a journey through to the deepest layer of Hell, passing down through layers of fire. Within this Ninth Layer there is no flame, there is a lake of ice. Imprisoned within this are the those of greatest evil, those of greatest betrayal. Rather a puzzle to me, this one. Is it a terrible place, manifesting evil incarnate? Or is Lake Cocytus a good thing, containing the world's greatest evils?

Good or evil this place, this Lake Cocytus, is my space to entomb the thoughts and musings best interred in ice.

"Because love is not sex or a shared faith, or the 'joint maintenance of a household and the upbringing of children'."
- Sergei Lukyanenko

"Look at that. Look at that. "Accident Blackspot"? These aren't accidents. They're throwing themselves into the road gladly. Throwing themselves into the road to escape all this hideousness."
- Withnail & I

"We know what happens to people who stay in the middle of the road. They get run down."
- Aneurin Bevan